The most Senior Student Affairs Officer should be the representative for the membership.

IN THE PAST, I HAVE BEEN A MEMBER OF NASPA ID #:

PREFIX:NAME: NICKNAME:

TITLE: FUNCTIONAL AREA:

INSTITUTION:

ADDRESS:

CITY: STATE/PROVINCE:

ZIP/POSTAL CODE: COUNTRY:

EMAIL ADDRESS: TELEPHONE #: FAX #:

DEMOGRAPHIC INFORMATION

The following information is collected so that NASPA can report aggregate statistical information to members and others in higher education. Individual personal information will not be released.

GENDER RACE/ETHNICITY M/NUFP ALUM HIGHEST DEGREE EARNED YEAR OF 1ST FULL-TIME

q Female q African American q Yes q Associate POSITION IN

q Male q American Indian q No q Bachelor's STUDENT AFFAIRS

q Transgender q Asian Pacific Islander q Master's

q Prefer Not to q Caucasian q Post Master's Certificate q 19

Answer q Hispanic/Latino q Doctorate/Terminal q 20

q  Multiracial

q  Other

q  Prefer Not to Answer

Circle the category in the “Institutional Dues Matrix” that represents your institutional makeup.

Total Education & General Fund Expenditures (in US$, excl. auxiliaries) / 0-499 / 500-999 / 1,000- 1,999 / 2,000- 3,499 / 3,500- 4,999 / 5,000- 7,999 / 8,000- 10,999 / 11,000- 14,999 / 15,000- 19,999 / 20,000- 29,999 / Over 30,000
0- 1,999,999 / 315 / 410 / 529 / 612
2,000,000- 3,999,999 / 336 / 439 / 549 / 633 / 753
4,000,000- 5,999,999 / 355 / 452 / 575 / 668 / 791 / 899
6,000,000- 9,999,999 / 375 / 474 / 595 / 708 / 818 / 929 / 1,021
10,000,000- 14,999,999 / 395 / 518 / 620 / 744 / 883 / 996 / 1,125 / 1,244
15,000,000- 19,999,999 / 415 / 538 / 658 / 782 / 896 / 1,009 / 1,139 / 1,265 / 1,392
20,000,000- 29,999,999 / 435 / 569 / 679 / 800 / 960 / 1,040 / 1,163 / 1,290 / 1,432 / 1,541
30,000,000- 49,999,999 / 457 / 586 / 714 / 825 / 973 / 1,079 / 1,208 / 1,327 / 1,448 / 1,570 / 1,689
50,000,000- 99,999,999 / 475 / 604 / 744 / 863 / 1,003 / 1,151 / 1,273 / 1,420 / 1,570 / 1,701 / 1,821
100,000,000-1 75,999,999 / 495 / 617 / 769 / 883 / 1,021 / 1,170 / 1,310 / 1,439 / 1,598 / 1,717 / 1,839
176,000,000- 250,000,000 / 545 / 657 / 799 / 928 / 1,073 / 1,187 / 1,347 / 1,485 / 1,625 / 1,757 / 1,856
More than 250,000,000 / 554 / 688 / 825 / 959 / 1,087 / 1,226 / 1,364 / 1,505 / 1,643 / 1,775 / 1,887

A check or money order (payable to NASPA) or credit card payment for the total amount in U.S. funds must accompany this form.

Return this form and payment to: NASPA CL ID# 500016 P.O. Box 5007, Merrifield, VA 22116-5007 or fax to (202)898-5737

Card Holder Name: Signature: ____

VISA MASTERCARD AMERICAN EXPRESS Card Number: Exp. Date: